Liver Trauma

Objectives

• To outline evaluation and management of Liver trauma in children

Back ground

• To create a document for rapid review of this commonly encountered injury

Why the liver…

• Friable parenchyma, thin capsule, fixed position in relation to spine

prone to blunt injury .• Right lobe larger, closer to ribs. more injury• In children compliant ribs, transmitted force

Mechanism of injury

• Deceleration injury --producing a laceration of its relatively

thin capsule and parenchyma at the sites of attachment to the diaphragm

• Crush injury --direct blow to the abdomen --damage to the central portion of the

liver

Blunt trauma

Penetrating injuries

Pearl

• posterior segment of the right liver lobe is the most frequently injured part. This part also involves the bare area and this can lead to retroperitoneal bleeding rather than bleeding into the peritoneal cavity.

Associations

• Isolated liver injury occurs in less than 50% of patients.

• Blunt trauma 45% with spleen• Rib fracture 33% with Liver injury

Injuries

• Contusion• Laceration• Subcapsular hematoma • Parenchymal damage• Hepatic vascular disruption• Bile duct injury

Grading

Grading outcomes

• Grade I,II ---minor injuries, represent 80-90% of all

injuries, require minimal or no operative treatment

• Grade III-V -- severe, most managed conservatively but

surgical intervention is occasionally needed• Grade IV --incompatible with survival

Diagnosis of liver injury

• Ultrasonography --fast, accurate, noninvasive, a good initial

screening test --sensitivity 88%, specificity 99• DPL --fast, sensitive, accurate and simple to perform --invasive, cannot diagnose retroperitoneal

injury

Computed tomography

• The standard evaluation method for stable patient

• Performed with Dilute water soluble oral contrast agent and intravenous contrast

Classification(AAST)

• I-Subcapsular hematoma<1cm, superficial laceration<1cm deep.

• II-Parenchymal laceration 1-3cm deep, subcapsular hematoma1-3 cm thick.

• III-Parenchymal laceration> 3cm deep and subcapsular hematoma> 3cm diameter.

• IV-Parenchymal/supcapsular hematoma> 10cm in diameter, lobar destruction

• V- Global destruction or devascularization of the liver.

• VI-Hepatic avulsion

Management

Conservative treatment

• 86% of liver injuries have stopped bleeding by the time of surgical exploration• 67% of operations performed are

nontherapeutic• Standard method of pediatric patient

for the past 20 years, with a success rate of 90%

Criteria for conservative treatment

hemodynamically stable simple hepatic parenchyma laceration of

inrahepatic hematoma absence of active hemorrhage limited need for liver related blood

transfusions absence of peritoneal sign absence of other peritoneal injuries that

would otherwise require an operation

Complications of conservative treatmentConservative treatment

Delayed hemorrhage

Stable

CT scan

Liver

injury

worse

Angiogram

Embolization

Liver injur

y unchanged

Search

for ot

her causes

Unstable

Exploration

Hemobilia Bili Hemia Liver abscess

Operative treatment

• Initial hemostasis Packing Pringle maneoevre Bimanual liver compression Cross clamping aorta above celiac trunk

Blood supply

• Portal vein• Hepatic artery• Hepatic vein

Liver segments

Technique

• Hepatotomy with direct suture ligation using the finger fracture technique,

electrocautery or an ultrasonic dissector to expose damaged vessels and hepatic duct

low incidence of rebleeding, necrosis and sepsis

Resection and debridement

Surgical options

Anatomical resection --reserved for deep laceration involving major

vessels or bile ducts, extensive devascularization and major hepatic venous bleeding

Perihepatic packing --Indication:coagulopathy, irreversible shock from

blood loss , hypothermia(32C), acidosis(PH7.2), bilobar injury,large nonexpanding hematoma, capsular avulsion, vena cava or hepatic vein injuries

Perihepatic packing

Mesh Wrapping

Ultrasonic dissector

Harmonic scalpel

Argon Coagulation

Tissue link

Outcome

Liver regeneration post resection of the right liver

The mortality rate from liver trauma has fallen from 66 per cent in World War I, to 27 per cent in World War II, to current levels of 10-15 per cent

Summary

• Liver 2nd most commonly injured solid organ.• Hemodynamic stability is the principle guide

to management.• Resuscitation is of primary importance rather

than wasting time and blood on grading either outside or inside the theatre.

•Thank you